Provider Demographics
NPI:1801884879
Name:PERRY, BRUCE ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLEN
Last Name:PERRY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 16TH ST NE
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:AL
Mailing Address - Zip Code:35555-1340
Mailing Address - Country:US
Mailing Address - Phone:205-932-5286
Mailing Address - Fax:205-932-8577
Practice Address - Street 1:124 16TH ST NE
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:AL
Practice Address - Zip Code:35555-1340
Practice Address - Country:US
Practice Address - Phone:205-932-5286
Practice Address - Fax:205-932-8577
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS449TA072152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL008600530Medicaid
AL000059749Medicare PIN
AL008600530Medicaid
AL0171120001Medicare NSC